How Forced Births Will Affect Women’s Healthcare

From Kate Riga of Talking Points Memo:

… The Supreme Court has not only let red states flip the calendar pages back to pre-1973 America. In many ways, it’s worse than that.

Abortion has become a foundational pillar to all kinds of health care procedures. Ripping it out [reduces their availability].

America now faces a reality that will be like returning to the early ‘70s, but with half a century of medical and technological advances that health care providers in certain states can no longer use. Since Roe, abortion care became drastically safer and more efficient, and the medical procedures involved in abortion have become indelibly embedded in the wider health care landscape. They’ve become a key aspect of all kinds of other health care, from miscarriage management to cancer treatment.

Now, in states from Texas to Ohio, we’re already seeing how abortion — or procedures that can be construed as abortion — are deeply intertwined with health care more broadly, and what it means for them to be taken away.

It’s easier, and convenient for the anti-abortion movement, to imagine abortion as a siloed-off procedure, under the auspices of Planned Parenthood and only relevant to young women seeking to end their unwanted pregnancies. But for decades, that hasn’t been the case.

After Roe, Abortion Becomes Safe

After the Supreme Court legalized abortion nationwide, researchers and physicians could finally learn how to get better at it.

“If the procedure is illegal, you can’t do clinical studies and you can’t develop new procedures because you’re doing it secretly,” Johanna Schoen, a professor of history at Rutgers University told TPM. “Most people providing abortions were not clinicians and not able to do it in a medical setting.”

“After Roe, clinicians made it not only the safest out-patient procedure in the country, but also much safer than pregnancy and delivering a baby,” she added. “All of that has to do both with the improvement of abortion procedures and development of new ones.”

In addition to the procedure improvements, after Roe, physicians started receiving more training in how to perform abortions and manage potential complications. Mortality rates associated with abortion started to plummet. And the number of women hospitalized for abortion-related complications dropped between 1970 and 1977, with a steep dip after 1973. By 1995, fewer than 0.3 percent of abortion patients were hospitalized with complications from the procedure.

Abortion Is Now Woven Throughout Today’s Medical Landscape 

While abortion care developed apace, other related medical technologies improved too. By the late 1970s, ultrasounds were being used widely in American hospitals, helping to advance detection of fetal abnormalities.

As the technology continued to improve over the next few decades, physicians became better able to identify abnormality markers. Under Roe, in states that hadn’t impinged on the abortion right with gestational bans (many diagnoses occur in the second trimester, though advances are pushing some earlier), women could opt for an abortion once abnormalities were detected rather than carrying the pregnancy to term.

Now, after Dobbsexperts are certain that women in states with draconian abortion bans will have to go through labor and give birth to babies that cannot survive.

The development of ultrasound technology has also enabled physicians to more accurately diagnose unruptured ectopic pregnancies in a way that was not possible pre-Roe. In these pregnancies, the fertilized egg implants outside of the uterus where it cannot survive but can pose a deadly threat to the woman if it’s allowed to grow.

The improvement in mortality rates associated with ectopic pregnancies followed: a more than 70 percent decrease in deaths-to-cases from 1970 to 1978.

Already, stories are emerging about the demise of Roe throwing ectopic pregnancy care into chaos. Doctors report feeling unsure about whether abortion bans — which are often written using broad political messaging language rather than medical — include ending ectopic pregnancies, which are not viable. Various lawmakers and anti-abortion activists have proven themselves to be particularly unlearned on the subject, some suggesting that terminating ectopic pregnancies is not medically necessary, while others have offered up a supposed solution — just moving the ectopic pregnancy inside of the uterus — technology for which does not currently exist.

Another medical success story already under threat is in-vitro fertilization, or IVF. The first IVF baby was born in 1978; since then, initial single-digit success rates have blossomed to nearly 50 percent for cases where the woman is under 35 years old. One to two percent of births in the United States annually result from IVF.

Fertility clinics have already been flooded with calls by people panicked about what abortion bans mean for their procedures. During IVF, clinicians usually implant one or two embryos in the uterus and store the rest for potential future use. It’s unclear whether bans would stop people from discarding the unneeded embryos, perhaps forcing them to pay to keep them frozen forever. Genetic testing of the embryos could become illegal. And if some embryos don’t survive the implantation process — or are nonviable and discarded — clinics could potentially be liable.

Some states are already contemplating granting personhood to the embryos, which could put IVF clinics out of business and leave the people who depend on them without options.

Far-Reaching Consequences

Even cancer treatment, a seemingly far cry from reproductive care, depends on abortion to afford its patients the right to treat their illnesses without worrying about the oftentimes toxic effect those treatments have on fetuses.

Cancer occurs in about one in every 1,000 pregnancies annually, leaving the women with few options even while Roe’s protections were the law of the land. Many treatments can cause miscarriages or birth defects in the developing fetuses, especially at the beginning of the pregnancy. The CEO of the American Cancer Society said that radiation therapy is never given to pregnant patients at all.

Ending their pregnancies, for these patients, can become a matter of literal life and death — the only way for women to receive the full gamut of treatment to cure their cancer. Now, in some states, women may have to choose: lifesaving treatment that will harm the developing fetus, or leaving their cancer untreated.

Some pharmacists are already restricting patients’ access to methotrexate, a therapy for certain kinds of cancer that can induce abortions. Methotrexate is also used in treating ectopic pregnancies and, since the 1980s, soothing chronic inflammation and pain, making it a mainstay in treating diseases like lupus, rheumatoid arthritis and psoriasis. The Arthritis Foundation has stood up a hotline amid reports of patients struggling to obtain the drug.

Two other pills — mifepristone and misoprostol, the collective “abortion pill” approved by the Food and Drug administration for combined used through 49 days of gestation in 2000, and for longer now — are already being acutely targeted by anti-abortion lawmakers. There’s a long history of animosity towards mifepristone in particular, with the FDA baselessly categorizing it as dangerous for years.

Those medications are indispensable in treating miscarriages, which at least one in four American women will have by age 45. Even before the Dobbs ruling, women have had to rely on abortion clinics for miscarriage treatment, often because of arbitrary limitations on who can distribute mifepristone. That problem has been compounded since the ruling by sparking confusion among some hospitals about whether other aspects of miscarriage care will be misconstrued by authorities as an elective abortion.

“Management of miscarriages and ectopic pregnancies are things that were not really possible when abortion was illegal,” Schoen said. “Women in the middle of miscarriages and ectopic pregnancies were up shit’s creek — and people died as a result of that.”

Abortion is a medical success story. Bringing the procedure out of the shadows allowed clinicians to make it safe and humane, and to weave it into other medical treatments. Procedures that are related to, or can be construed as abortion, are now integral parts of an astoundingly wide range of medical care. All of it is under threat.

The Supreme Court is not sending large swaths of the country back to the relative ignorance of pre-Roe America. It’s sending us back in time armed with prodigious knowledge and then-undreamed-of technology that lessen women’s suffering, and uncomplicate and alleviate illnesses where pregnancy is not an option — but forbidding health care workers to use that knowledge.

Women will suffer and they will die, even while doctors have 50 years of medical advancements at their backs….

Requiem for the Supreme Court

That’s the title of an article by Linda Greenhouse, the longtime observer of the Supreme Court for the New York Times. She writes:

They did it because they could.

It was as simple as that.

Greenhouse is no firebrand, but she concludes that the Court’s reactionaries have destroyed “the legitimacy of the Court”.

The title of Jill Filipovic’s article for The Guardian is “It’s time to say it: the US supreme court has become an illegitimate institution”. She writes:

As of 24 June 2022, the US Supreme Court should officially be understood as an illegitimate institution – a tool of minority rule over the majority, and as part of a far-right ideological and authoritarian takeover that must be snuffed out if we want American democracy to survive.

On Friday, in Dobbs v Jackson Women’s Health, the supreme court overruled its nearly 50-year precedent of Roe v Wade, the 1973 case that legalized abortion nationwide. It is difficult to overstate just how devastating this is for pregnant people, for women as a class and for anyone with even a passing interest in individual freedom and equality.

But it’s also devastating for those of us who care quite a bit about American democratic traditions and the strength of our institutions. Because, with this ruling, the Supreme Court has just signaled its illegitimacy – and it throws much of the American project into question. Which means that Democrats and others who want to see America endure as a representative democracy need to act.

Of the nine justices sitting on the current court, five – all of them in the majority opinion that overturned Roe – were appointed by presidents who initially lost the popular vote; the three appointed by D____ T____ were confirmed by senators who represent a minority of Americans. A majority of this court, in other words, were not appointed by a process that is representative of the will of the American people.

Two were appointed via starkly undemocratic means, put in place by bad actors willing to change the rules to suit their needs. Neil Gorsuch only has his seat because Republicans, led by Mitch McConnell, blocked the ability of Barack Obama to nominate Merrick Garland – or anyone – to a supreme court seat, claiming that, because it was an election year, voters should get to decide.

And then D____ T____ appointed Amy Coney Barrett in a radically rushed and incomplete, incoherent process – in an election year.

And now, this court, stacked with far-right judges appointed via ignoble means, has stripped from American women the right to control our own bodies. They have summarily placed women into a novel category of person with fewer rights not just than other people, but than fertilized eggs…. After all, no one else is forced to donate their organs for the survival of another – not parents to their children, not the dead to the living. It is only fertilized eggs, embryos and fetuses that are newly entitled to this right to use another’s body and organs against that other’s will; it is only women and other people who can get pregnant who are now subject to these unparalleled, radical demands.

This raises a fundamental question: can a country be properly understood as a democracy – an entity in which government derives its power from the people – if it subjugates half of its population, putting them into a category of sub-person with fewer rights, freedoms and liberties?

The global trend suggests that the answer to that is no. A clear pattern has emerged in the past few decades: as countries democratize, they tend to liberalize women’s rights, and they expand abortion and other reproductive rights. Luckily for the women of the world, this is where a great many nations are moving.

But the reverse is also true: as a smaller number of countries move toward authoritarian governance, they constrict the rights of women, LGBT people and many minority groups. We have seen this in every country that has scaled back abortion rights, reproductive rights, and women’s rights more broadly in the past several years: Russia, Hungary, Poland, Nicaragua and the United States.

The same week that the Supreme Court issued its decision in Dobbs, the US House of Representatives has been holding hearings to inform the public about what actually happened during the attempted coup of 6 January 2021, and to ideally hold perpetrators, traitors and seditionists to account. We are only a year and a half past that disgraceful day, when an angry mob decided that they, an authoritarian, patriarchal, white supremacist minority, should rule – that any other outcome, no matter how free and fair the election, was illegitimate.

The Supreme Court decision stems from that same rotted root: the idea that a patriarchal minority should have nearly unlimited authority over the majority. The [reactionaries] on the court rightly understand that individual rights and women’s freedoms are incompatible with a system of broad male control over women and children, and a broader male monopoly on the public, political and economic spheres.

But that authoritarian vision is also incompatible with democracy.

And so Democrats now have a choice. They can give speeches and send fundraising emails. Or they can act: declare this court illegitimate. Demand its expansion. Abolish the filibuster. Treat this like the emergency it is, and make America a representative democracy.

They’re Not Even Trying To Be Consistent. Or Honest. Or Historically Accurate.

Texas can regulate abortion but New Jersey can’t regulate guns.

And lying to Congress is a crime:

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By the way (from historian J. M. Opal):

The 2nd Amendment, ratified in 1791, reads: “A well regulated Militia being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” Responsible readings of this sentence note that it locates gun rights within the framework of militia service, not as an individual entitlement. By contrast, the 5th Amendment, ratified the same year, says that “No person” shall be denied due process.

Militias aside, there is also the “keep and bear” part of the 2nd Amendment to consider. In the founders’ era, to “keep” meant to own and possess something inside one’s home, while “bear arms” referred specifically to shouldering a musket or rifle in an army or militia.

Nowhere does the amendment declare or suggest a right to “go armed,” the term used in that era for carrying a weapon such as a pistol or dagger, either openly or in secret.

The Fix Is In at the Supreme Court

The draft opinion overturning Roe v. Wade is built on the assumption fetuses deserve special treatment while denying that assumption is being made. Liza Batkin explains with “Deceit in Plain Sight” for the New York Review of Books:  

Justice Alito’s draft opinion in Dobbs v. Jackson Women’s Health Organization would have you believe that the forthcoming decision to overrule Roe v. Wade is a display of great judicial restraint and independence. The draft is written in the language of solemn duty: we do not want to take away abortion rights, the conservative justices say, but it does not matter what we want. “We can only do our job,” Alito writes, “which is to interpret the law,” and to do so regardless of personal preferences or public opinion. In the draft decision’s logic, it was Roe that exercised “raw judicial power” and Dobbs that will remedy this error by returning “the issue of abortion to the people’s elected representatives.”

These claims to neutrality and humility should make you nauseous and irate. For one thing, they come in the middle of a decision that would wield extraordinary power, disposing with a nearly half-century-old fundamental right and reshaping the lives of millions of Americans. It’s also skin-crawling that these justices pretend to be concerned with empowering “the people” through their representatives after eroding the voting rights and electoral rules that would have allowed them to be adequately represented.

This performance of duty comes from justices who have routinely championed religious interests, were nominated by Republican presidents, and have all been affiliated with the Federalist Society, an organization dedicated to promoting conservative legal ideology. While only Justice Barrett has made explicit her personal opinions about abortion, stating in a co-authored law review article in 1998 that it is “always immoral,” the others are clearly not sacrificing their moral or political views for some higher charge.

You don’t need to look very far to see that the decision is a power grab cloaked in false modesty. The flaws in the majority’s central argument, that Roe was wrong to recognize a fundamental right to abortion, have been well-exposed elsewhere. But there is another deceit at play here: while claiming fidelity to the constitutional text, the majority’s draft is steeped in unexplained views about the importance of protecting fetuses at all stages of development—views that do not come from the Constitution but have traditionally been the purview of conservative and religious antiabortion advocates, and that are exactly the kind of personal belief the majority claims not to rely on.

The issue of abortion since Roe has been a battle between competing rights: a pregnant person’s right to control their reproductive choices, and the state’s interest in protecting the potential life of a fetus. To balance these different interests, the Court has historically tried to avoid opining on the legal or moral claims of fetuses, since the issue teems with conflicting beliefs. One way to establish when the state’s interest in protecting potential life becomes compelling, the Court recognized in Roe, was to determine “when life begins.” But after a brief survey of opposing religious, philosophical, and theological views, the Court steered clear of the mire and landed instead on the line of viability, which protects the right to abortion until the fetus can survive outside the womb.

If you take Alito at his word, the Dobbs majority has managed to sidestep this balancing act altogether. The draft decision proclaims that it is “not based on any view about when a State should regard prenatal life as having rights or legally cognizable interests” and says little about the source, strength, or timing of the state’s interest in potential fetal life.

But the majority has not avoided the issue. While claiming high-minded neutrality, they hint over and over at views about the importance of protecting fetal life. Early in the opinion, Alito explains that abortion “is fundamentally different” from all other liberty interests “because it destroys what [Roe and Casey] called ‘fetal life’ and what the law now before us describes as an ‘unborn human being.’” As a result, the right to abortion presents a distinct and “critical moral question.” The draft makes this point four times.

There is, however, no reason to assert that abortion at all stages of a pregnancy presents a unique and “critical moral question” unless one already gives weight and legitimacy to moral claims for the protection of fetuses at all stages of development, starting even as soon as conception. How else can we explain the draft opinion’s circular insistence that the right to abortion is different from other rights simply because it destroys fetuses, which merely defines what an abortion does?

The terms the draft uses, too, are revealing. In veering from the “potential life” invoked by Roe and Casey and repeating without qualification the language used by the Mississippi legislature along with antiabortion amicus briefs that defend the rights of the “unborn human being” and the “unborn child,” the majority divulges its allegiances. The footnotes tell the same story. In addition to citing a large array of prior dissenting opinions by conservative justices which have no legal authority, the draft draws on amicus briefs and articles dedicated to proving that fetuses are people. Alito’s majority does all of this while claiming that it “has neither the authority nor the expertise to adjudicate” disputes about “the status of the fetus” and citing language that courts must not “substitute their social and economic beliefs for the judgment of legislative bodies.”

While we rally to protect the right of pregnant people to make decisions about their bodies and futures (and desperately hope that this draft decision does not become law), we should recognize what’s going on here. The [reactionary] justices are preparing to abuse their power, cause grievous harm, and treat us—the “people” they pretend to empower—like fools, assuming we won’t notice the contradictions they’ve left in plain sight.

Even If a Fetus Is a Person (It’s Not), a Woman Still Has Rights

A fertilized egg isn’t yet a person, despite beliefs, mainly religious, to the contrary. But what if we assume that it is? What would that mean with regard to a pregnant woman’s rights? Alec Walen is a philosophy professor with a law degree. He explains:

The discussion in the media in the wake of the leaked draft opinion making it plain that Roe v. Wade will fall has focused on the impact the decision will have on women who will lose the right to abortion in many states, the potential political impact of the decision, and what other rights may fall next. What’s missing is a discussion of the legal implications of taking the view of the fetus that was upheld in Justice Alito’s draft, that it is an “unborn human being,” i.e., a person.

Saying that fetal personhood is inconsistent with a right to abortion opens up deep moral tensions in the law. These tensions can be resolved in one of three ways. The right way to resolve these tensions is also something that we, as a society, need to examine.

The tensions result from an observation made by [the philosopher] Judith Jarvis Thomson in 1971: if a woman is forced to carry a fetus to term—forced by threat of prosecution, either of abortion providers or perhaps of her—then she is forced to serve as the unwilling life support system for this other person. The problem is that the freedom not to have to serve others is a fundamental principle in our law.

The Thirteenth Amendment to the U.S. Constitution holds that “Neither slavery nor involuntary servitude, except as a punishment for crime whereof the party shall have been duly convicted, shall exist within the United States, or any place subject to their jurisdiction.” As Justice Hughes explained in 1911, in Bailey v. Alabama, “The plain intention [of the Thirteenth Amendment] was to… make labor free, by prohibiting that control by which the personal service of one man is disposed of or coerced for another’s benefit which is the essence of involuntary servitude.”

Forcing a woman to serve as the life support system for a fetus for up to nine months, when she does not want to do so, flatly runs up against this fundamental principle. The question is: are there other exceptions, other than that listed in the Thirteenth Amendment itself—as punishment for a crime—that can be defended.

Option 1: Revise two basic limits regarding service.

First limit: on specific performance.

One argument that is sometimes made on behalf of requiring women to carry a fetus to term is that parents have a general duty to care for their children. We require fathers to provide child support after a child is born even if the father would have wanted the pregnancy aborted or the child given up for adoption. If we can require fathers to care for children financially, then we can require women to carry them to term before choosing whether to raise them or give them up for adoption.

But there is a long-standing distinction in the law between requiring monetary payments, when the person has the means to make them, and providing specific performance. Child support payments are tied to the income of the father or, more broadly, the non-custodial parent. A father can be required to work to provide financial support for his children, but he cannot be forced to do some specific task. This is quite different from forcing a woman to carry a child in her body. The degrees of freedom left to fathers, to find a job that suits them, are qualitatively different from the specific, often dangerous performance of the “job” of carrying an unwanted fetus to term.

One might respond that specific performance is required of parents: they have to feed their children and take them to the doctor when they are sick. Failure to do these things can lead to charges as severe as murder if the child dies.

The problem with this response is that these specific, positive duties are contingent on being a custodial parent. At least in our society—and in the vision of Justice Barrett—parents should be free to choose whether to be custodial parents or not. If they give them up for adoption, then they lose all duties of care; if they choose not to play a custodial role but the other parent retains a custodial role, then they are responsible only for financial support. In other words, while it is true that parents can find themselves with duties of specific performance, that is only if they have chosen those duties.

Are we willing, then, to overturn the general ban on unchosen duties of specific performance?

Second limit: intrusions on bodily integrity

Bodily integrity is deeply important in the law. As Justice Cardozo wrote in 1914 . . . in the case called Schloendorff v. Society of New York Hospital, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.”

But a woman forced to carry an unwanted pregnancy has to endure an unwanted physical intrusion in her body. To equate the service required of a woman who carries an unwanted child to that of a father who has to pay child support within his means overlooks not only the specific performance dimension, but the fact that an unwanted fetus constitutes a bodily intrusion.

If we wanted a better analog to pregnancy, it would be giving up a kidney—a serious intrusion into the body, with small but serious health risks involved. We do not now require fathers to give up a kidney to save a child who might need one.

Are we willing to require fathers to put their bodies on the line in the same way as mothers?

 Option 2: Revision of the equality of the sexes

If we are not willing to make the two revisions just mentioned, there is another way to resolve the tensions raised by recognizing fetuses as persons and concluding that pregnant women may not choose to abort them: abandon the assumption that women have the same rights as men. We could say again, as once was clearly said, that women are not equal citizens. If they become pregnant, they have to serve the interests of the fetus they carry whether they want to or not. They have to carry burdens that fathers would never be asked to carry for their children.

One who finds this appealing might say: yes, and men have their own burdens to carry. God, they might say, made men and women different; men are built to fight and protect the home, women are built to bear and nurture children. This is the natural order of things.

This is a view that many find appealing. But it is a view greatly at odds with our modern, liberal, egalitarian conception of the law. It is a view closer to that of Gilead, the fictional dystopia in Margaret Atwood’s The Handmaid’s Tale than our current legal order.

Are we willing to cast aside our modern, liberal-egalitarian order for some variation on Gilead?

Option 3: Recognize the right to abort fetal persons

If we are unwilling to take options 1 or 2, the third option is to maintain the right to abortion.

Adopting this third option does not mean adopting the Roe framework, with its focus on fetal viability. It might allow the state to recognize the value of fetal life by, for example, giving women a limited time to decide whether they want to carry a fetus to term. If a woman discovers that she is pregnant and does not decide to abort within that window, then she has effectively chosen to bear a duty of specific performance. She thereby presumptively waives her right not to carry it to term.

This too would need further refinement, as unforeseen conditions might arise that should revive her right to abort. For example, she might discover that she suffers a medical condition that makes carrying the fetus to term vastly more difficult and dangerous than she expected. These details, too, should be part of our conversation.

But the bottom line is this: if we are unwilling to take option 1 or 2, some basic right to abortion should be retained even if we assume that fetuses are persons.

Unquote.

Judith Jarvis Thompson’s classic essay, “A Defense of Abortion” is available here.